High Claim Denials, Limited Visibility, and Revenue Leakage: Why Analytics-Driven RCM Is the Only Way Forward

If there’s one frustration nearly every healthcare organization shares in 2026, it’s this:

“We know revenue is leaking,  we just can’t see exactly where or why.”

High denial rates, slow appeals, and payer friction are not new problems. What is new is the scale — and the cost.

MGMA benchmarking shows that denial rates exceeding 10% are no longer rare, particularly for services with authorization or medical necessity scrutiny. At the same time, CMS and OIG data continue to show that a large percentage of denied claims are ultimately payable  meaning the issue isn’t eligibility, but process breakdown.

Denials aren’t just a billing problem. They’re a visibility problem.

Why Denials Feel Worse Than Ever

Most revenue cycle teams face the same obstacles:

• Fragmented systems that don’t talk to each other
• Manual reporting that arrives too late to drive change
• Limited insight into payer-specific behavior
• KPI tracking that focuses on outcomes, not causes
  
  

OIG enforcement trends reinforce this reality. Reviews consistently identify documentation gaps, medical necessity inconsistencies, and authorization failures — not fraudulent intent — as drivers of payer scrutiny.

The result is a familiar pattern:

• Claims deny
• Appeals pile up
• Staff chase symptoms instead of root causes
• Leadership sees revenue flatten despite strong volume

The Real Cost of Poor Visibility

When organizations lack actionable analytics:

• Denials repeat for the same reasons
• Underpayments go unnoticed
• Contracted rates aren’t enforced
• Staff time shifts from prevention to cleanup
  
  

MGMA has repeatedly emphasized that denial prevention costs a fraction of denial recovery, yet many organizations remain trapped in reactive workflows because they can’t see trends early enough to intervene.

This is where analytics-driven RCM changes the equation.

What Analytics-Driven RCM Actually Means

This isn’t about dashboards for dashboards’ sake.

Effective revenue analytics answer operational questions like:

• Which payers are driving the highest avoidable denials?
• Which services break most often — and why?
• Where do authorization delays create A/R bottlenecks?
• Which documentation gaps correlate with medical necessity denials?
  
  

When analytics are tied directly to workflow:

• Processes improve
• Denials decline
• Cash flow stabilizes
• Staff focus shifts upstream

🔗 See how ADSRCM uses analytics to reduce denials and protect revenue

Where AI Fits — and Where It Doesn’t

AI alone doesn’t fix denials. But when applied correctly, it:

• Identifies patterns humans can’t see quickly
• Flags documentation risk earlier in the workflow
• Supports consistency without replacing clinical judgment
  
  

This is especially important as payers increasingly mirror OIG enforcement priorities in their edits and audits.

🔗 Learn how ADSRCM integrates AI responsibly into RCM workflow

In 2026, denial management isn’t about working harder, it’s about seeing clearly.

Organizations that combine analytics, workflow discipline, and intelligent automation don’t just recover revenue — they stop losing it in the first place!

ADSRCM supports AI-driven technology and a behind-the-scenes team of experts to maximize revenue and productivity. The same automation we use – the MedicsCloud Suite – is available from ADS if an in-house platform is preferred. ADSRCM and ADS clients can also access the ONC-certified MedicsCloud EHR or retain their existing EHRs if preferred. 

Contact us at 844-599-6681 or email info@adsc.com for more about the approach that works best for you.